Adhesive Capsulitis: A Sticky Issue

LORJ B. SIEGEL. M.D., NORMAN |. COHEN, M.D., and ERIC P. GALL, M.D.
Finch University of Health Sciences/Chicago Medical School, North Chicago, Illinois

The shoulder is a very complex joint that is crucial to many activities of daily living.
Decreased shoulder mobility is a serious clinical finding. A global decrease in shoulder O A patient informa-
range of motion is called adhesive capsulitis, referring to the actual adherence of the tion handout on adhe-
sive capsulitis. written
shoulder capsule to the humeral head. Adhesive capsulitis is a syndrome defined as idio-
by the authors of this
pathic restriction of shoulder movement that is usually painful at onset. Secondary causes article, is provided on
include alteration of the supporting structures of and around the shoulder, and autoim- page 1851.
mune, endocrine or other systemic diseases. The three defined stages of this condition are
the painful stage, the adhesive stage and the recovery stage. Although recovery is usually
spontaneous, treatment with intra-articular corticosteroids and gentle but persistent
physical therapy may provide a better outcome, resulting in tittle functional compromise.

T
he shoulder is a complex ana-
tomic structure that allows
movement in many planes.
Physicians and patients alike
don't often think about the
importance of the shoulder joint until its func-
tion becomes compromised. It then becomes
obvious how crucial it is for many essential
activities. The expression "If you don't use it,
you lose it" applies perfectly to diseases of the
shoulder because any voluntary or involuntary
guarding of the shoulder may result in loss of
mobility. The term "frozen shoulder" has been
loosely applied to conditions when tbe shoul-
der is working at less than its optimal range.
Because the shoulder joint is so complex, it is
important to determine the precise cause for
loss of shoulder mobility. It is paramount that
physicians use proper terminology so that they
can communicate effectively and treat patients
appropriately.
Definition of Terms
Many terms are used to describe limitation
of shoulder movement, and all of them imply
a stiff shoulder with decreased range of
motion (Table 1). These terms are attempts to
describe the probable underlying pathophys-
iologic process (i.e., bursal or capsular origins
of inflammation). They were used to describe
conditions that are difficult to understand
and explain and, although of historic interest,
they are confusing and are best discarded.
The term "frozen shoulder" encompasses
many of the concepts of the terms in Table 1,
but it too is confusing and not always accu-
rate. The correct term for true global decrease
in shoulder range of motion is adhesive cap-
sulitis, related to the surgical findings of
actual adherence of the capsule to the
humeral head.'''
Adhesive capsulitis is a syndrome defined
in its purest sense as idiopathic painful
restriction of shoulder movement that results
in global restriction of the glenohumeral
joint. It is not associated with a specific un-
derlying condition. It has also been described
as a condition of "unknown etiology charac-
terized by gradually progressive, painful
restriction of all joint motion . .. with spon-
taneous restoration of partial or complete
motion over months to years."' To avoid con-
fusion, the term "adhesive capsulitis" should
be used to reter to the primary idiopathic
condition and the term "secondary adhesive
capsulitis" should be applied to the condition
that is associated with, or results from, other
pathologic states. Each case must be evaluated
TABLE 1
Terms Used to Describe
Limited Shoulder Mobility
Frozen shoulder Periarthritis
Adhesive capsulitis Adherent bursitis
Pericapsulitis Obliterative bursitis

APRIL 1, 1999 / VOLUME 59, NUMBER 7 AMERICAN FAMILY PHYSICIAN 1843

 to determine if the restriction is idiopathic
(primary) or the result of an underlying sys-
temic illness or anatomic process (secon-
dary). Either condition causes pain and
decreased shoulder mobility.
Subacromial or subdeltoid bursitis
Bicipital tendinitis
(insertion of the long
head of the biceps
muscle in the
bicipital groove)
Acromioclavicular
joint arthritis
Rotator cuff tendinitis
FIGURE 1. Anatomy of shoulder in diagnosis of shoulder pain.
FIGURE 2. Note the marked limitation of active abduction of the left
shoulder in a patient with adhesive capsulitis.
Differential Diagnosis
Complaints of shoulder pain or movement
problems are difficult to evaluate. Many
shoulder conditions have similar symptoms,
causes, precipitating factors and treatments.
Multiple pathologic lesions may be present in
a single joint."* In assessing a patient's shoulder
pain, the physician must distinguish between
true glenohumeral joint problems and extra-
articular derangements. Active range of
motion will most likely be limited and painful
in both cases, but decreased passive range of
motion, which is often painful as well, most
likely indicates true joint pathology.
If the patient is able to relax and the exam-
iner can elicit full passive range of motion, the
etiology of the pain is most likely to be extra-
articular. Prolonged soft tissue problems, how-
ever, may eventually lead to decreased shoulder
range of motion because of the patient's con-
stant guarding of the shoulder. It is imperative
to determine the precise source of shoulder
pain (Figure 1) so that a program of physical
therapy can be initiated to prevent compro-
mise of shoulder movement (Figure 2). Extra-
articular pain may result from strain or
inflammation of muscles, tendons or bursae.
The differential diagnosis of shoulder prob-
lems is protean, but physicians should be able
to readily recall some of the more common
causes of shoulder pain and decreased range of
motion. Bicipital tendinitis may affect active
shoulder movement and is diagnosed by elicit-
ing tenderness while pressing on the long head
bicipital tendon in the bicipital groove. The
bicipital tendon passes through the gleno-
humeral joint.
Pain on extension may be elicited by testing
for Yergason's .sign (Figure 3). The patient is
asked to resist supination of the forearm
while the physician presses on the bicipital
tendon in the groove on the humerus. Pain
with resisted forward flexion (Speed's test),
may also be present (Figure 4).
Tendinitis of the rotator cuff is the most
common cause of shoulder pain and sec-

1844 AMERICAN FAMILY PHYSIC3AN VOLUME 59, / APRIL 1,1999

FIGURE 3. Yergason's sign. The patient resists
supination of the forearm while the physician
presses on the bicipjtal tendon.
ondary decreased shoulder mobility that
manifests with pain on passive and active
abduction.•^•'' Pain is usually greater with inter-
nal rotation of the shoulder than with external
rotation. The key finding is pain in the rotator
cuff on active abduction, especially at 60 to
100 degrees of abduction. Ultimately, there
may be impingement and a loss of mobility.
Tenderness may be elicited anteriorly over tbe
humeral bead when the arm is extended. Cal-
cific tendinitis may also lead to impingement.
The subacromial and subdeltoid bursae are
contiguous in most persons. Subacromial
bursitis manifests with pain when the patient
lies on bis or her shoulder, or with tenderness
on palpation of the space on the lateral aspect
of the shoulder just inferior to the acromion
along tbe deltoid. Subacromiat bursitis may
also be a reactive phenomenon in a patient
with a rotator cuff injury. Acromioclavicular
joint problems, commonly including osteo-
arthritis, may also result in decreased passive
joint range of motion and local tenderness.
True shoulder pain presents with tenderness
on anterior or posterior palpation. Decreased
joint motion is compensated for by an increase
in scapulothoracic motion during flexion and
abduction. Increased scapulothoracic motion
stresses other structures around the shoulder
and may result in more global pain syndromes,
guarding and decreased range of motion.
APRIL 1,1999 / VOLUME 59, NUMBER 7
FIGURE 4. Speed's test. The patient is asked to
flex the forearm while the physician provides
resistance.
The evaluation of shoulder instability is
important in patients with shoulder pain.
Symptomatic subluxation may clinically
mimic an acute rotator cuff injury or bicipital
tendinitis. A high index of suspicion and a
detailed physical examination combining the
assessment of laxity in all directions witb
stress tests can belp the physician determine
the underlying cause of pain. Correction of
any muscle imbalance is paramount to
preservation of mobility and function. Mus-
cles around tbe neck and shoulder girdle
should be palpated for tenderness or trigger
points to assess for fibromyalgia, myofascial
pain syndromes and cervical osteoarthritis.
The correct diagnosis in a patient witb
restricted shoulder movement on pbysical
examination and any of the previously men-
tioned findings, sucb as bursitis or tendinitis, is
secondary adhesive capsulitis. Tbe underlying
condition is documented as the primary prob-
lem leading to secondary adhesive capsulitis.
Adhesive Capsulitis
FEATURES, PRESENTATION AND NATURAL HISTORY
Primary idiopathic adhesive capsulitis is
difficult to defme, diagnose and manage. This
condition affects 2 to 3 percent of tbe popula-
tion. It tends to occur in patients older tban 40
years of age and most commonly in patients
in their 50s and in women. Fifteen percent of
AMERICAN FAMILY PHYSICIAN 1845
 Adhesive capsulitis has three defined stages: the painful
stage, the adhesive stage and the recovery stage.
patients develop bilateral disease. Adhesive
capsulitis has been reported in children.^
The natural history of adhesive capsulitis
and its dinicai course is divided into three
stages: the painful stage, the adhesive stage
and the recovery stage (Tnble 2). The painfiil
stage involves gradually increasing pain and
stiffness and lasts between three and eight
months. Muscle spasms in the trapezius also
commonly occur during this phase. A history
of a minor strain or injury before onset may
be noted; however, it is unclear whether the
initial strain is an independent phenomenon
or an early awareness of the pain associated
with the onset of adhesive capsulitis.
Commonly, patients note a decreased abil-
ity to reach behind the back when fastening a
garment or removing a wallet from a back
trouser pocket. The initial discomfort is
described by many patients as a generalized
shoulder ache with difficulty pinpointing the
exact location of the discomfort. The pain
may radiate both proximally and distally, is
aggravated by movement and alleviated with
rest. Sleep may be interrupted if the patient
rolls on the involved shoulder.
This condition progresses to one of severe
pain accompanied by stiffness and decreased
range of motion. The stiffening increases to
the point where the natural arm swing that
accompanies normal gait is lost." The patient
tries to compensate for this loss by using
other muscles and increasing scapular rota-
tion to accomplish various activities. This
places additional strain on the other muscle
groups, leaving them overworked and tender.
The physical examination during the
painful stage of adhesive capsulitis may reveal
muscle spasm and diffuse tenderness about
the glenohumeral joint and the deltoid mus-
cle. An area of pinpoint tenderness is seldom
found. With disease progression and in long-
standing cases, disuse atrophy of the shoulder
girdle may result. Passive and active range of
motion in all planes of shoulder movement
are lost (Figure 5). This global loss of motion
is the primary factor distinguishing adhesive
1846 AMERICAN FAMIIV PHYSICIAN
capsulitis from many of the conditions asso-
ciated with secondary adhesive capsulitis.
The second stage, the adhesive stage,
involves increasing stiffness with diminishing
pain. Pain decreases at night, and discomfort
occurs only at the extremes of motion, al-
though movement is dramatically decreased.
This stage lasts four to six months.
The final stage, called the recovery stage,
lasts from one to three months and is charac-
terized by minimal pain but severe restriction
of movement. This latter stage is self-limiting,
with a gradual and spontaneous increase in
range of motion. Complete recovery, how-
ever, is infrequent. Tbe external rotation
range of motion improves first, followed by
abduction and internal rotation. Short recov-
ery periods may have associated bouts of pain
before each phase of improvement. Although
approximately 7 to 15 percent of patients per-
manently lose their full range of motion, only
a few have a true functional disability.**"*
PATHOLOGY
The pathophysiology of primary and sec-
ondary adhesive capsulitis remains elusive. It is
believed that in patients with diabetes, associ-
ated microvascular disease causes abnormal
TABLE 2
The Three Stages of Adhesive Capsulitis
Painful stage
Pdin with movement
Generalized ache that is difficult to pinpoint
Muscle spasm
Increasing pain at night and at rest
Adhesive stage
Less pain
Increasing stiffness and restnction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges of movement
Recovery stage
Decreased pain
Marked restriaion with slow, gradual increase in
range of motion
Recovery is spontaneous but frequently incomplete
, NUMBER 7 / APRIL 1,1999

FIGURE 5. Decreased passive extension in a
patient with adhesive capsulitis.
collagen repair, which predisposes them to
adhesive capsulitis. Occasionally, fibrous
strands are seen traversing the joint space (Fig-
ure 6). Patients with diabetes often present
with fibrosis elsewhere (i.e., Dupuytren's con-
tracture). Irauma, the associated transient
inflammatory state with granulation tissue,
and eventual fibrous adhesions and thickening
of the capsule may cause adhesive capsulitis.'"
Immobilisation is an intriguing possible
etiologic factor for adhesive capulitis in pa-
tients with stroke or postmyocardial infarc-
tion; however, prolonged casting studies have
not supported this theory." Neuropathic
mechanisms, including suprascapular nerve
compression, have been considered, but none
accounts for mo.st cases of adhesive capsulitis.
Although strong evidence suggests an associa-
tion among these neuropathic and vascular
conditions and adhesive capsulitis, no patho-
physiologic mechanisms are convincing.
Theories regarding autoimmune reaction
to tendon degeneration have led to immuno-
FIGURE 6. In a patient with diabetes and adhesive capsutitis, MRI of the shoulder (left) reveals a
fibrous band traversing the glenohumeral joint space (arrow).
1,1999 / VOLUME 59, NUMBER 7
Adhesive Capsulitis
logic investigations. Although random and
inconsistent, the inflammatory indexes mea-
sured (e.g., erythrocyte sedimentation rate)
were partially supported because they were
slightly elevated and improved as the disease
improved." Synovial fluid offers no clues to
the etiology of adhesive capsulitis. Biopsies of
the synovial lining have revealed increased
fibroblasts and vascular dilatation, but few or
no perivascular inflammatory cells.
EVALUATION
The diagnosis of adhesive capsulitis is pri-
marily clinical. In general, the scapular rota-
tion occurs at 60 degrees with active abduc-
tion of the shoulder. In an unaffected person,
the shoulder can be passively abducted to 90
degrees even when the physician holds the
scapula. Inability to achieve the 90-degreearc
with scapular stabilization is the clue to the
diagnosis in both primary and secondary
adhesive capsulitis. It is important to assure
that the scapula is secured when assessing
passive range of motion (Figure 7).
Radiographs are important in assessing
restricted range of motion in the diagnosis of
secondary adhesive capsulitis. Osteoarthritis,
fracture, avascular necrosis, crystalline ar-
thropathy, calcific tendinitis and neoplasm
may be detected on plain radiographs. Radio-
graphs of patients with early adhesive capsuli-
L
AMERICAN FAMILY PHYSICIAN 1847
 have normal findings. Arthrography should
be reserved for use in patients whose diagno-
sis remains uncertain following physical
examination and radiography.
Arthroscopy may have a limited role in the
FIGURE 1. Markedly decreased passive abduction is shown in a patient diagnosis of other diseases that mimic adhe-
with adhesive capsulitis, with the scapula stabilized to prevent early sive capsulitis, but it does not aid in the diag-
scapulothoracic movement.
nosis of adhesive capsulitis itself and is not
used frequently.'- The usefulness of magnetic
tis are normal. Later changes sometimes show resonance imaging (MR!) in the diagnosis of
osteopenia, q'st-like changes in the humeral adhesive capsulitis has also been evaluated.''
head and joint-space narrowing. A chest radio- Studies revealed that some changes seen on
graph may be useful in establishing the diag- MRI are specific and sensitive for adhesive cap-
nosis of tuberculosis or malignancy-associ- sulitis; however, the decrease in joint fluid is
ated adhesive capsulitis. not appreciated. MRI may become a useful,
Arthrography, although invasive, is useful to noninvasive way to document capsular thick-
document decreased joint volume. The unaf- ening, but further studies are needed. I n most
fected shoulder will accommodate 20 to 30 cases, the diagnosis of adhesive capsulitis is
mL of contrast material, whereas the shoulder clinical; however, if any imaging is necessary,
with adhesive capsulitis will only be able to arthrography remains tlie procedure of choice.
hold 5 to 10 mL. Arthrograms may reveal an If there are no underlying illnesses, laboratory
irregularity of the capsular insertion at the investigations will be unremarkable.
anatomic humeral neck and a decreased axil-
lary fold. From 10 to 30 percent of patients are Other Causes of
found to have a demonstrable rotator cuff tear Secondary Adhesive Capsulitis
at arthrography, yet a significant number also Some systemic diseases are known to be
associated with adhesive capsulitis (Table 3)
and should be considered in patients with
restricted shoulder movement. Trauma, avas-
The Authors cuiar necrosis and osteoarthritis may predis-
pose a patient to secondary adhesive capsuli-
LORI 8. SIEGEL. M.D., is chief of the Division of Rheumatology at Finch University of
Health Sciences/Chicago Medical School, North Chicago, III. She is director of under- tis. Systemic diseases such as diabetes,
graduate education in the Department of Medicine, Dr. Siegel received her medical hyperth}Toidism and rheumatoid arthritis are
degree from the Medical College of Wisconsin, Milwaukee, and completed a resi-
also associated with secondary adhesive cap-
dency in intemal medicine and a fellowship in rheumatology at Georgetown Univer-
sity Hospital, Washington, D.C. sulitis and must be considered in a patient
with limited range of motion of the shoul-
NORMAN J. COHEN, M.D,, IS an orthopedic surgeon in private practice and clinical
assistant professor in the Department of Surgery at Finch University of Health Sci- jgj.i-1,15 Patients often have referred shoulder
ences/Chicago Medical School. He is also on staff at Highland Park (III,) Hospital. Dr, pain from the heart, neck, diaphragm, liver or
Cohen received a medical degree from Albert Einstein College of Medicine of Yeshiva spleen. It is unclear why patients with a history
University, Bronx, N.Y., and completed training in general surgery and orlhopedic
surgery at the University of Illinois College of Medicine, Chicago. of myocardial infarctions, cerebrovascular
accidents and chronic pulmonary diseases,
ERIC P GALL, M.D,, is professor and chairman of the Department of Medicine at Finch
University of Health Sciences/Chicago Medical School, Dr, Gall is also professor of
such as tuberculosis and pulmonary cancer,
immunology and microbiology at the same institution. He received his medical degree are also predisposed to adhesive capsulitis.
from the University of Pennsylvania School of Medicine, Philadelphia, where he also Patients with reflex sympathetic dystrophy
completed a residency in internal medicine and a fellowship in rheumatology
(related to some of these events) may have
Address correspondence to Lori B. Siegel, M.D., Division of Rheumatology, Finch Uni- restricted range of motion of the shoulder
versity of Health Sciences/Chicago Medical School, 3333 Green Bay Rd., North
Chicago, IL 60064. Reprints are not available from the authors.
that becomes permanent in the later stages of

1848 AMERICAN FAMILY PHYSICJAN VOLUME 59, NUMBER 7 / APRIL, 1,1999


disease. Some patients may also develop reflex
sympathetic dystrophy as a result of primary
or secondary adhesive capsulitis.
Management
Although studies comparing various treat-
ment modalities for adhesive capsulitis reveal
that no specific treatment method has any
long-term advantage, early and accurate diag-
nosis is imperative.'*' In patients with adhesive
capsulitis, the goal of treatment is pain reduc-
tion and preservation of shoulder mobility.
Thefirststep is preventing secondary adhesive
capsulitis by definitively addressing underly-
ing causes. Avoiding prolonged immobiliza-
tion in patients who may be predisposed to
adhesive capsulitis is crucial.
Treatment of a shoulder injury of any etiol-
ogy requires early range of motion therapy to
reduce muscle spasm while maintaining full
range of motion. Heat, cold and other modal-
ities that relax the muscles may help preserve
range of motion. Adequate analgesia is neces-
sary for successful treatment in this phase.
Vigorous and forceful exercises are con-
traindicated because of the pain associated
with the rupture of adhesions. Also, the more
painful treatment regimens have been found
to be associated with a higher level of non-
compliance. Constant encouragement is nec-
essary for patients with adhesive capsulitis,
since resolution may be slow. Gradually
increasing the range of motion of the shoul-
der will decrease the pain associated with the
disease. Physical therapy done at home,
including Codman exercises, "climbing the
wall" or placing things up higher to encour-
age reaching, is cost effective but requires a
long rehabilitative process.''
Nonsteroidal anti-inffammatory drugs
(NSAIDs) help to relieve pain and inflamma-
tion. Analgesics are indicated when NSAIDs
are contraindicated. Muscle relaxants are
helpful in the early stages of the disease when
spasm is predominant. Low-dose antidepres-
sant medications (e.g., 10 mg of amitriptyline
[Elavil] taken at night) may help to avoid a
APRIL 1,1999 / VOLUME 59, NUMBER 7
Inability to passively abduct the shoulder in a 90-degree arc
with scapuiar stabilization indicates primary or secondary
capsulitis.
cycle of sleep disturbance leading to a chronic
pain syndrome and fibromyalgia.*
Intra-articular corticosteroid injections are
used in affected patients to relieve pain and
permit a more vigorous physical therapy rou-
tine. The injection site is located 1 cm distal
and 1 cm lateral to the coracoid process'^
(Figure 8). Full external rotation of the
humerus with the elbow held in a relaxed
position at the patient's side helps open up the
space, which is difficult to enter if contracted
by adhesive capsuHtis.'"^ The usual dosage is 15
to 40 mg of triamcinolone acetonide (Kena-
log) or another depot steroid with 1 mL of 1
percent lidocaine. Although intra-articular
corticosteroids are frequently used, no long-
term benefits fi-om this therapy (i.e., shorter
time to fijll recovery) have been proved. Some
clinicians advocate simultaneous intra-articu-
lar and bursal injections for pain relief before
beginning physical therapy. Oral corticos-
teroids are not helpful.
Severe adhesive capsulitis diagnosed in the
later stages is more difficult to manage. The
above treatments, useful on occasion, are not
always successful. Surgical intervention
should be considered when physical therapy
and injections fail (no improvement after
three months of therapy). Manipulation
under anesthesia to break up the adhesions is
reserved for use in the adhesive stage. During
this procedure, the joint capsule and sub-
scapular muscles are ruptured, and aggressive
rehabilitation is employed to restore and
maintain range of motion of the shoulder.
TABLE 3
Diseases and Conditions Associated
with Secondary Adhesive Capsulitis
Diabetes me!litus Pulmonary tuberculosis Scleroderma
Chronic lung disease Postmastectomy
Thyroid illness
Trauma Myocardial infarction Cervical radiculitis
Rheumatoid arthritis Cerebrovascular
Lung cancer accidents/hemiplegia
AMERICAN FAMILY PHYSICIAN 1849
Adhesive Capsulitis
Patients undergoing manipulation may
receive an intra-articular corticosteroid injec-
tion after the procedure and begin physical
therapy the day of the procedure. Icing is
often helpful.
Another option is the administration of an
interscalene block before the manipulation;
this renders the patient painfreeand allows for
the immediate start of physical therapy. Risks
associated with manipulation under anesthe-
sia include humeral fracture, dislocation and
rotator cuff rupture. Contraindications to
manipulation include severe osteopenia, a his-
tory of fracture or dislocation, or recurrence
following adequate manipulation.'^ For
patients with loss of motion refractory to
closed manipulation, arthroscopic capsular
release has been shown to improve motion
with minimal operative morbidity.^" In this
study, most patients had a marked decrease in
pain, and functional improvement. Some
investigators-' demonstrated that arthroscopic
release was helpful in patients with diabetes-
associated adhesive capsulitis who were refrac-
tory to conservative measures. Thirteen of the
patients studied had no pain, full range of
motion and full function after surgical release.
Interestingly, a marked discrepancy exists
between the patient's subjective awareness of
residual range deficit and the measurable
(objective) restrictions. Many patients with
range deficits regard their recovery as com-
FIGURE 8. Anterior approach to glenohumeral joint injection for adhe-
sive capsulitis.
1850 AMERICAN FAMILY PHYSICIAN
plete. This difference in subjective and objec-
tive assessment of recovery, plus the variation
and confiasion in the definitions of adhesive
capsulitis, may account for the conflicting
reports of prognosis and therapy.'^
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VOLUME 59, NUMBER 7 / APRIL 1,1999